Sylvie Delacroix

The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics - A Study of Medical Ethics Using Immersive Virtual Reality

Background Dealing with insistent patient demand for antibiotics is an all too common part of a General Practitioner’s daily routine. This study explores the extent to which portable Immersive Virtual Reality technology can help us gain an accurate understanding of the factors that influence a doctor’s response to the ethical challenge underlying such tenacious requests for antibiotics (given the threat posed by growing anti-bacterial resistance worldwide). It also considers the potential of such technology to train doctors to face such dilemmas. Experiment Twelve experienced GPs and nine trainees were confronted with an increasingly angry demand by a woman to prescribe antibiotics to her mother in the face of inconclusive evidence that such antibiotic prescription is necessary. The daughter and mother were virtual characters displayed in immersive virtual reality. The specific purposes of the study were twofold: first, whether experienced GPs would be more resistant to patient demands than the trainees, and second, to investigate whether medical doctors would take the virtual situation seriously. Results Eight out of the 9 trainees prescribed the antibiotics, whereas 7 out of the 12 GPs did so. On the basis of a Bayesian analysis, these results yield reasonable statistical evidence in favor of the notion that experienced GPs are more likely to withstand the pressure to prescribe antibiotics than trainee doctors, thus answering our first question positively. As for the second question, a post experience questionnaire assessing the participants’ level of presence (together with participants’ feedback and body language) suggested that overall participants did tend towards the illusion of being in the consultation room depicted in the virtual reality and that the virtual consultation taking place was really happening.

A Discussion of Virtual Reality As a New Tool for Training Healthcare Professionals

Background Virtual reality technology is an exciting and emerging field with vast applications. Our study sets out the viewpoint that virtual reality software could be a new focus of direction in the development of training tools in medical education. We carried out a panel discussion at the Center for Behavior Change 3rd Annual Conference, prompted by the study, “The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics––A Study of Medical Ethics Using Immersive Virtual Reality” (1). Methods In Pan et al.’s study, 21 general practitioners (GPs) and GP trainees took part in a videoed, 15-min virtual reality scenario involving unnecessary patient demands for antibiotics. This paper was discussed in-depth at the Center for Behavior Change 3rd Annual Conference; the content of this paper is a culmination of findings and feedback from the panel discussion. The experts involved have backgrounds in virtual reality, general practice, medicines management, medical education and training, ethics, and philosophy. Viewpoint Virtual reality is an unexplored methodology to instigate positive behavioral change among clinicians where other methods have been unsuccessful, such as antimicrobial stewardship. There are several arguments in favor of use of virtual reality in medical education: it can be used for “difficult to simulate” scenarios and to standardize a scenario, for example, for use in exams. However, there are limitations to its usefulness because of the cost implications and the lack of evidence that it results in demonstrable behavior change.

G162 Evidence that an immersive virtual reality scenario can be used to train safeguarding to doctors in primary care

Introduction Most child protection will be seen in primary care but is often subtle. Methods We invited GPs to undertake a medical consultation in a virtual reality ‘cave’. We obtained ethical approval from UCL for this being a covert child safeguarding scenario: participants were informed that they were testing the use of Virtual Reality in GP consultation. We produced a simulated consultation using two avatars: Chris, who came for a medically challenging consultation, and his accompanying 6 year old son Tom. Safeguarding cues presented were either subtle or obvious. Chris was angry towards his son, refused to allow Tom to go to the toilet and appeared to swipe at him. Results We recruited 63 GPs (26 male; 33 female) who ranged in age from 25 to 59 years and had worked between 1 and 36 years. Fourteen GPs failed to detect the safeguarding cues (3 in the obvious cue scenario and 13 in the subtle cue scenario). Analysis of the post scenario questionnaire provides useful information about the use of virtual reality in medical training. One important question posed after the scenario was ‘Were you concerned about Tom’s relationship with Chris?’ This clearly cued those who hadn’t picked up on this previously. All participants including these 14 GPs made comments that they had some concerns about what was going on (see Table). One participant’s comments sum it up well. ‘He swiped at him at the beginning of the consultation, made a disparaging comment and did not let him go to the toilet’. Discussion The GPs responses to this virtual reality scenario were very interesting. Most of their comments can be applied to real life scenarios but this has to take advantages over using role play often considered as the ‘gold-standard’. Young children cannot be used as actors as they are unable to divorce play from reality. This becomes even more pertinent if the subject matter is child protection where there is something unpalatable about using young children who are being abused. By directly filling the questionnaires after undertaking the scenario those who had missed that this was a safeguarding scenario could be cued in a way to reconsider what had happened in a private and constructive way.

G146 Can a virtual reality communication scenario be used to teach general practitioners and trainees how to recognise and manage safeguarding issues

Background Immersive reality has been demonstrated to be an exciting educational tool in clinical consultations. Research groups internationally continue to explore new uses for this technology. Safeguarding is a challenging area of practice where we must listen to the child, and tackle difficult conversations with parents. As it is unethical to ask children to role play being abused, computer generated characters could have a key role in educating healthcare professionals on how to manage difficult scenarios. Aim To assess the interaction between doctors and a vulnerable child in a virtual reality safeguarding scenario. Methods All doctors at several local GP practices were offered inclusion in the study in early 2017. They were placed in an immersive virtual reality consultation where we tested their ability to pick up covert safeguarding cues within a consultation with an adult patient. After the consultation, they typed up their notes electronically as they would in their day-to-day practice. We have analysed their videoed consultations with the child and used a team of experts to rank their notes on how well they managed the safeguarding concern. Results We recruited 63 participants in total; 37 GPs and 26 trainees, and 73% identified the safeguarding element of the consultation. Following the consultation only 14% of GPs identified asking the vulnerable child in the scenario about his relationship with his father. Negative responses ranged from comments such as ‘No, I thought the ‘agenda’ item was the letters’ to ‘I could/should have asked him directly if everything was ok at home’ to ‘I wasn’t sure that I should ask Tom questions without a parent present as he is only 6’. Conclusion The fact that 73% of participants identified the safeguarding element shows that it was identifiable within the consultation and highlights the usefulness of immersive reality as a training tool. However, it also demonstrates a need for further training to increase the recognition rate. The range of interactions with the child demonstrates that some GPs are clearly skilled at interacting with children and others less confident. Their videoed virtual reality consultations would be a useful safeguarding training tool.

Drafting a Constitution for a "Country of words" 1

Can words – rather than a State (or army) – constitute a country? It may be made of land, rivers, forests or deserts – yet, without its inhabitants’ words, there would be no map to draw, no tale to sing, no country to speak of. Palestinian tales abound. They speak of departed lands, vanished homes, forfeited livelihoods. They lament internal wrangling, squeal occupational anger, seek to whisper away those quotidian checkpoint humiliations. Yet, they also speak of hope. If there ever were such a thing as “authoritative hope”, the ongoing Palestinian constitution drafting process may be it. But hope cannot be formalized, let alone authorized. And there is some danger in pretending otherwise.

Making law bind: legal normativity as a dynamic concept

If ever there were an opportunity to ‘spring-clean’ jurisprudence of its most cumbersome words, ‘normativity’ would be high on the list. It sounds ugly, and it’s come to be associated with a frustratingly vague array of questions.

Montaigne's inquiry into the sources of normativity

How can one explain the normative outcome of the initial law-creating practices without any reference to some pre-existing natural laws guaranteeing the lawgivers enterprise? The challenge which the rejection of the classical natural law model represents amounts to explaining the normative dimension of law despite the arbitrariness of the social practices from which it stems. Montaigne gave both an exemplary formulation and a peculiar solution to that question: in order to reconstruct the authority of law despite the dangerous arbitrariness from which it flows, Montaigne decides to avoid any inquiry regarding the original law-creating practices by positing a law of pure obedience.